Provider Demographics
NPI:1033203088
Name:AVIDOR, BONEH G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BONEH
Middle Name:G
Last Name:AVIDOR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-1321
Mailing Address - Country:US
Mailing Address - Phone:631-744-3458
Mailing Address - Fax:
Practice Address - Street 1:10 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-1321
Practice Address - Country:US
Practice Address - Phone:631-744-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013307-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01808424Medicaid
NYV93011Medicare ID - Type Unspecified